SBC0143W041820171237 BASE PLAN OPTION Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: Beginning on or after 06/01/2017 HUMANA INSURANCE COMPANY: TN NCR PPO 16-SEP ACC&CPY OV, IP, OP 51-100 Coverage for: Individual + Family Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, www.groupcertificate.humana.com or by calling 1-866-4ASSIST (427-7478). For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-866-4ASSIST (427-7478) to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-of-pocket limit for this plan? What is not included in the out-of-pocket limit? Network: $0 Individual / $0 family; Non-Network: $5,000 Individual / $10,000 family Doesn't to prescription drugs and network preventive services. Coinsurance and copayments don't count toward the deductible Network Providers: Not applicable. Non-Network Providers: Yes. Emergency Room Care and Prescription Drugs. No For network providers $6,500 individual / $13,000 family; For non-network providers $19,500 individual / $39,000 family Premiums, Balance-billing charges, Health care this plan doesn't cover, Penalties, Non-network transplant, non-network prescription drugs, non-network specialty drugs Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. This plan does not have a network deductible. This plan covers some items and services even if you haven't yet met the deductible amount. But a copayment or coinsurance may. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. You don't have to meet deductibles for specific services. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Even though you pay these expenses, they don't count toward the out of pocket limit. S041817 1 of 9
Will you pay less if you use a network provider? Do you need a referral to see a specialist? Yes. See www.humana.com/directories or call 1-866-4ASSIST (427-7478) for a list of network providers For Prescription Drugs: National Rx Network No This plan uses a provider network. You will pay less if you use a provider in the plan's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common What You Will Pay Limitations, Exceptions, & Other Important If you visit a health care provider's office or clinic If you have a test Primary care visit to treat an injury or illness Specialist visit Preventive care / screening / immunization $30 copay/office visit; $75 copay/visit; No charge None None You may have to pay for services that aren't preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. Diagnostic test: Cost share may vary based on where service is performed Diagnostic test (x-ray, blood work) does not Imaging: Cost share may vary based on where service is performed Imaging (CT/PET scans, MRIs) $500 copay; deductible does not 2 of 9
Common What You Will Pay Limitations, Exceptions, & Other Important If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.humana.com Level 1 - Lowest cost generic and brand-name drugs $10 copay (Retail); $25 copay (Mail Order); Network copay (Retail); Network copay (Mail Order); deductible does not 30 day supply obtained, penalty will be 100% for certain prescription drugs (Retail) 90 day supply obtained, penalty will be 100% for certain prescription drugs (Mail Order) Non-network cost sharing does not count toward the out-of-pocket limit. Level 2 - Higher cost generic and brand-name drugs Level 3 - Generic and brand-name drugs with higher cost than Level 2 Level 4 - Highest cost drugs $40 copay (Retail); $100 copay (Mail Order); $70 copay (Retail); $175 copay (Mail Order); 25% coinsurance (Retail); deductible does not 25% coinsurance (Mail Order); deductible does not Network copay (Retail); Network copay (Mail Order); deductible does not Network copay (Retail); Network copay (Mail Order); deductible does not Network copay (Retail); Network copay (Mail Order); deductible does not 3 of 9
Common What You Will Pay Limitations, Exceptions, & Other Important If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you need mental health, behavioral health, or substance abuse services Specialty drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room care Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fee Outpatient services Inpatient services 35% coinsurance; $1000 copay/visit; does not $500 copay/visit; $500 copay/transport; $125 copay/visit; $1000 copay/day; does not $30 copay/visit; $1000 copay/day; ; None $500 copay/visit; $500 copay/transport; None 25% coinsurance when filled via a preferred network specialty pharmacy obtained, penalty will be 100% for certain prescription drugs Emergency room care: Copayment waived if admitted 3 days for copay per day Inpatient services: 3 days for copay per day 4 of 9
Common What You Will Pay Limitations, Exceptions, & Other Important If you are pregnant Office visits: Cost sharing does not for preventative serices. Office visits does not Childbirth/delivery professional services: Depending on the type of services, a deductible may. Childbirth/delivery facility services: Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound) 3 days for copay per day Childbirth/delivery professional services does not Childbirth/delivery facility services. $1000 copay/day; If you need help recovering or have other special health needs Home health care $75 copay/visit; 100 visits per year 5 of 9
Common What You Will Pay Limitations, Exceptions, & Other Important Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice services $75 copay/visit; to Manipulations, Occupational Therapy, Speech Therapy, Audiology Therapy, Cognitive Therapy, and Physical Therapy $75 copay/visit; to Manipulations, Occupational Therapy, Speech Therapy, Audiology Therapy, Cognitive Therapy, and Physical Therapy $75 copay/day; does not does not None Therapies: Manipulations and Therapies: 60 Physical Therapy, Occupational Therapy, Speech Therapy, Cognitive Therapy, Audiology Therapy visit limit per year includes manipulations & adjustments For non-network, 10 Physical Therapy, Occupational Therapy, Cognitive Therapy, Speech Therapy, Audiology Therapy visits per year includes manipulations & adjustments 60 days per year for durable medical equipment $750 and over 6 of 9
Common What You Will Pay Limitations, Exceptions, & Other Important If your child needs dental or eye care Excluded Services & Other Covered Services: Children's eye exam Not Covered Not Covered None Children's glasses Not Covered Not Covered None Children's dental check-up Not Covered Not Covered None Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of other excluded services.) Acupuncture, unless it is prescribed by a Cosmetic surgery, unless to correct a functional Private-duty nursing physician for rehabilitation purposes impairment Bariatric surgery Dental care (Adult), unless for dental injury of a Routine eye care (Adult) sound natural tooth Child dental check-up Infertility treatment Routine foot care Child eye exam Long-term care Weight loss programs Child glasses Non-emegency care when traveling outside of the U.S Other Covered Services (Limitations may to these services. This isn't a complete list. Please see your plan document.) Chiropractic care - spinal manipulations are covered Hearing aids Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or http://www.dol.gov/ebsa/healthreform or Department of Health and Human Services, Center for Consumer and Insurance Oversight, at 1-877-267-2323 x61565 or http://www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.healthcare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Humana, Inc.: www.humana.com or 1-866-4ASSIST (427-7478). Department of Labor Employee Benefits Security Administration: 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform Tennessee Department of Commerce and Insurance, 500 James Robertson Parkway, Davy Crockett Tower, Nashville, TN 37243-0565, Phone: 615-741-2241, Website: http://www.state.tn.us/commerce/index.shtm 7 of 9
Does this plan provide Minimum Essential Coverage? Yes. If you don't have Minimum Essential Coverage for a month, you'll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet Minimum Value Standards? Yes. If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. To see examples of how this plan might cover costs for a sample medical situation, see the next page. 8 of 9
About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) The plan's overall deductible $0 Specialist copayment $75 Hospital (facility) copayment $1000 Other coinsurance 0% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,800 In this example, Peg would pay: Cost Sharing Deductibles $0 Copayments $1,000 Coinsurance $0 What isn't covered Limits or exclusions $0 The total Peg would pay is $1,000 Managing Joe s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition) The plan's overall deductible $0 Specialist copayment $75 Hospital (facility) copayment $1000 Other coinsurance 0% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400 In this example, Joe would pay: Cost Sharing Deductibles $0 Copayments $1,800 Coinsurance $0 What isn't covered Limits or exclusions $20 The total Joe would pay is $1,820 Mia s Simple Fracture (in-network emergency room visit and follow up care) The plan's overall deductible $0 Specialist copayment $75 Hospital (facility) copayment $1000 Other coinsurance 0% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $1,900 In this example, Mia would pay: Cost Sharing Deductibles $0 Copayments $1,600 Coinsurance $0 What isn't covered Limits or exclusions $40 The total Mia would pay is $1,640 The plan would be responsible for the other costs of these EXAMPLE covered services. 9 of 9